Direct comparison of simultaneous and sequential endoscopic metallic bilateral stenting in malignant hilar biliary obstruction.

Abstract

<h4>Background</h4>Endoscopic bilateral biliary drainage is a first line palliative treatment for unresectable malignant hilar biliary obstruction (MHBO) but remains technically challenging. The emergence of self-expandable metallic stents carried by an ultra-thin (6 Fr or smaller) delivery system now permits simultaneous bilateral stent placement. To date, only a few studies have compared this new method with conventional sequential bilateral stenting.<h4>Aim</h4>To evaluate a possible superiority of simultaneous "side by side" (SBS) biliary drainage in unresectable MHBO.<h4>Methods</h4>We identified 135 patients who benefited from bilateral drainage using uncovered self-expandable metallic stents between 2010 and 2023. Among them, 62 benefited from simultaneous SBS bilateral drainage between 2017 and 2023, and 73 benefited from sequential bilateral drainage [38 using "stent in stent" (SIS) technique and 35 using SBS technique between 2010 and 2017].<h4>Results</h4>Technical success was significantly increased in simultaneous drainage compared with sequential drainage (94% <i>vs</i> 75%, <i>P</i> = 0.008). However, simultaneous SBS drainage and sequential SIS drainage had a similar technical success (94% <i>vs</i> 95%). We observed no differences regarding clinical success, procedure duration and recurrent biliary obstruction rate. Stent patency was shorter in the SIS group compared with the simultaneous group (103 days <i>vs</i> 144 days). Early adverse events were more frequent in the sequential group (31% <i>vs</i> 21%, <i>P</i> = 0.205), with no differences regarding SIS or SBS technique. Technical failure was associated with a higher rate of infectious fatal adverse events (9.5% <i>vs</i> 1.7%, <i>P</i> = 0.02). Reintervention after recurrent biliary obstruction seems to be more successful after using SBS rather than SIS techniques (83% <i>vs</i> 75%, <i>P</i> = 0.53).<h4>Conclusion</h4>Simultaneous SBS metallic stent placement using an ultra-thin delivery system was technically easier and as efficient as sequential bilateral stenting in unresectable MHBO to achieve bilateral drainage. The SIS procedure remains a good option in unresectable MHBO.